01/01/2026 ASO Open Access Plus HDHPQ - HDHPQ 4500 Proclaim - 37302329 - V 33 - 10/20/25 05:26 PM ET 8 of 17 ©Cigna 2025 Benefit In-Network Out-of-Network Note: Services where plan deductible applies are noted with a caret (^). Plan deductible always applies before benefit copays/deductibles. Breast Feeding Equipment and Supplies  Limited to the rental of one breast pump per birth as ordered or prescribed by a physician  Includes related supplies Plan pays 100% Plan pays 50% ^ External Prosthetic Appliances (EPA) Plan pays 80% ^ Plan pays 50% ^  Annual Limit: Unlimited Temporomandibular Joint Disorder (TMJ)  Unlimited Non-Surgical lifetime maximum Coverage varies based on Place of Service Coverage varies based on Place of Service Note: Provided on a limited, case-by-case basis. Excludes appliances and orthodontic treatment. Routine Foot Care Not Covered Not Covered Note: Services associated with foot care for diabetes and peripheral vascular disease are covered when approved as medically necessary. Hearing Aids Plan pays 80% ^ Plan pays 50% ^  $2,500 maximum per Calendar Year  Includes testing and fitting of hearing aid devices at Physician Office Visit cost share Wigs  Maximum of 1 wig per Lifetime Plan pays 80% ^ Plan pays 80% ^ Travel Services  Authorized eligible travel and lodging expenses when an In- network facility/provider is not available within a 60 mile radius from your primary home residence.  Coverage for designated services only: services with state legislative limitations on access (e.g., abortion, gender affirmation services), In-patient and Outpatient Mental Health and Substance Use Disorder Services  Coverage when travelling to an in-network provider/facility only  Medical Annual Maximum: $10,000  Mental Health and Substance Use Disorder Maximum: Unlimited Plan pays 100% ^ Not Covered